Nursing Elites

1. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?

• A. Decrease the oxytocin infusion rate
• B. Determine current cervical dilation
• C. Request placement of the epidural
• D. Give a bolus of intravenous fluids

Correct answer: D

Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.

2. What action should be implemented when preparing to measure the fundal height of a pregnant client?

• A. Have the client empty her bladder.
• B. Request the client lie on her left side.
• C. Perform Leopold's maneuvers first.
• D. Give the client some cold juice to drink.

Correct answer: A

Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.

3. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?

• A. Jaundice.
• B. Poor feeding.
• C. Brain injury.
• D. Hypoglycemia.

Correct answer: A

Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.

4. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

• A. Urinary output and fluid intake.
• B. Hemoglobin and hematocrit.
• C. Abdominal contour and bowel sounds.
• D. Heart rate and blood pressure.

Correct answer: D

Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.

5. A client at 28 weeks gestation calls the antepartum clinic and reports experiencing a small amount of bright red vaginal bleeding without uterine contractions or abdominal pain. What instruction should the LPN/LVN provide?

• A. Come to the clinic today for an ultrasound.
• B. Go immediately to the emergency room.
• C. Lie on your left side for about one hour and see if the bleeding stops.
• D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

Correct answer: A

Rationale: Bright red vaginal bleeding without pain could indicate placental issues such as previa. An ultrasound is necessary to evaluate the cause. It is important to rule out potential serious conditions like placental previa, which can lead to further complications for both the mother and the fetus. Therefore, prompt evaluation through an ultrasound at the clinic is essential for appropriate management and ensuring the well-being of the client and her baby.

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